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eISSN: 2476-7425 pISSN: 2476-7417 JNFS 2017; 2(3): 243-258 Website: jnfs.ssu.ac.ir
This paper should be cited as: Sangsefidi ZS, Salehi-Abargouei A. Nutrition and Oral Health: Experiences in Iran.
Journal of Nutrition and Food Security (JNFS), 2017; 2 (3): 243-58.
Nutrition and Oral Health: Experiences in Iran
Zohre Sadat Sangsefidi ; MSc1, 2
& Amin Salehi-Abargouei; PhD1, 2*
1. Department of Nutrition, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
2 Nutrition and Food Security Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
ARTICLE INFO
ABSTRACT
REVIEW ARTICLE
Background: Oral health is a crucial factor for overall well-being and there is
a mutual relationship between nutrition and oral health. The aim of this study
was to review the publications which have examined the association between
nutrition or diet and oral health status or oral disease in Iran. Methods: The
electronic databases of PubMed, Scopus, Google scholar, scientific
information database (SID), and Magiran were searched using key words of
diet, nutrition, oral health, oral disease, and Iran to reach the related articles
published up to 2016. The English and Persian articles with cross-sectional,
clinical trial, prospective, and case-control designs were selected. The Persian
studies were then translated into English. The animal studies were not
investigated. Results: The findings showed that nutrition and diet were
associated with oral health. However, the majority of studies focused on
evaluation of the relation between nutrition and dental caries. Further, a few
studies were conducted on the association between nutrition and other oral
problems such as periodontal disease or oral cancer. Moreover, the limited
nutritional or dietary factors were investigated in the literature. Conclusions:
Nutrition and diet are related to oral health and prevention of oral disease.
Further studies are therefore recommended to evaluate the association between
nutrition and oral health with considering various dietary or nutritional factors
and different types of oral problems in Iran.
Keywords: Nutrition; Diet; Oral health; Oral diseases; Iran
Article history:
Received: 18 Jan 2016
Revised: 12 Mar2 017
Accepted: 20 May 2017
*Corresponding author:
Nutrition and Food Security
Research Center and
Department of Nutrition,
Faculty of Health, Shahid
Sadoughi University of
Medical Sciences, Yazd,
Iran.
Postal code: 6816163879
Tel: +983531492229
Introduction
ral health is essential for general well-being
and good quality of life; it refers to have
healthy teeth, gums, and lack of oral disease
(WHO, 2003). There is a close association
between nutrition and oral health. Studies showed
that nutrition and diet have a strong influence on
oral health. Additionally, an imbalanced diet is
associated with oral diseases such as periodontal
disease (PD), oral cancer, and dental disease. On
the other hand, oral diseases have a great impact
on the dietary intake and may lead to undesirable
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nutritional status and decrease quality of life
(Chicago, 2011, Dye et al., 2011, Reeves, 2010,
Scardina and Messina, 2012, Scardina and
Messina, 2008, Touger-Decker et al., 2003). The
present paper is intended to review the present
evidences on the relationship between nutrition
and oral health in Iran with a focus on oral
disease including dental carries, PD, and oral
cancer.
Materials and Methods
The various electronic databases including
PubMed, Scopus, Google scholar, scientific
information database (SID), and Magiran were
used for searching of the literature published up
to year 2016 using key words such as diet,
nutrition, dietary or nutritional factors,
nutritional status, oral health, oral disease, and
Iran. The relevant studies in English and Persian
with cross-sectional, clinical trial, prospective,
and case control designs were included. The
Persian articles were later translated into
English. The animal studies were not reviewed
in this study.
Results
Oral health problems and nutrition
1. Dental caries
Dental caries is one of the public health
problems worldwide (WHO, 2002). The
prevalence rate of caries is high in the developing
countries especially countries where fluoride is
not enough and consumption of free sugars and
other fermentable carbohydrates is high (Hong‐
Ying et al., 2002, Moynihan and Petersen, 2004).
Dental caries occur because of demineralization
of enamel and dentine by organic acids produced
by bacteria in dental plaque through the anaerobic
metabolism of fermentable carbohydrates found
in the diet (Moynihan and Petersen, 2004).
Dietary factors can be effective in prevention of
caries including increase in the fiber intake, diets
characterized by a ratio of many amides/little
sugars, cheese, nutrients especially calcium,
phosphorus, fluoride (Moynihan et al., 1999,
Scardina and Messina, 2012), vitamin D, vitamin
A, zinc, iron, and protein (Moynihan and
Petersen, 2004, Navia, 1996).
1.1 Dental caries and obesity
Both obesity and dental caries are considered
as major public health problems in the world
including developing countries (Popkin, 2001,
WHO, 2002). Dental caries and obesity are both
associated with dietary habits (Marshall et al.,
2007). In the last decade, consumption of sugar-
sweetened beverages, snack foods, fast foods, and
decrease in physical activity contributed to
obesity globally (Willershausen et al., 2004).
Moreover, along with the increase of obesity,
prolonged exposure to fermentable carbohydrates
by frequent consumption of high caloric and
cariogenic substances has been also linked to
dental caries (Hilgers et al., 2006, Kopycka‐
Kedzierawski et al., 2008, Palmer, 2005).
Furthermore, obesity is related to many non-
communicable diseases including oral disease
(Hilgers et al., 2006, Palmer, 2005). Several
studies have evaluated the association between
body mass index (BMI) and dental caries in
Iranian children and adolescents. The majority of
them focused on the relationship between BMI or
consumption of cariogenic foods and dental
caries. For instance, Malek Mohammadi et al.
evaluated the association between BMI and dental
caries among 420 children aged 6 years, in
Kerman. They used decayed, missing and filled
primary (dmft), as well as permanent teeth DMFT
for diagnosis. A significant association between
DMFT/dmft score and BMI was found (P = 0.04).
Interestingly they reported that, about 40% of
underweight children were in "very high caries"
group (Malek Mohammadi et al., 2012).
Similarly, in another study from Kerman in 2009-
2010, it was observed that caries rate reduced
with increase in body weight in a sample of 3–6
years old children (Bafti et al., 2015). However, a
cross-sectional survey on a population of children
aged 6-11 years in Isfahan indicated no
relationship between BMI-for-age and DFT/dft
(decayed and filled permanent/primary teeth)
indices (Sadeghi and Alizadeh, 2007). In addition,
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researchers conducted a cross-sectional study to
examine the relation between tooth decay and
BMI-for-age among a group of Iranian
adolescents in Rafsanjan (747 students aged 12-
15 years). They found no association between
DMFT scores and BMI-for-age (Sadeghi et al.,
2011). Meanwhile, the results of a study on 1213
children aged 6-11 years in Zahedan showed that
the mean DFT in the overweight children was
higher than that of underweight or normal
weight groups (Shahraki et al., 2013). In a
survey from Shiraz, Edalat et al. evaluated the
association between early childhood caries and
BMI in a population of 3- to 6-year-old children.
They reported that there is no significant
association between increasing dental caries on
the one hand and reducing height, weight, and
BMI on the other hand (Edalat et al., 2014).
Another study also reported no relationship
between tooth decay and BMI in a group of
children in Hamedan (Mojarad and Maybodi,
2011). Ghasempour et al. also investigated the
association between dental caries and BMI
among pre-school children in Babol. The results
indicated that the caries rate increased with the
increase of BMI (Ghasempour et al., 2011). But,
researchers did not find any relationship in a
population of female students (12-14 years old)
in Tehran (Faezi et al., 2013). In a survey on a
sample of children aged 7-11 years from Yazd, a
higher DMFT/dmft was observed in the group
with higher BMI (Bahrololoomi et al., 2014).
However, the findings of another study
suggested that DMFT decreases with increase of
BMI in 9-11 years old children in Shiraz
(Khosravani et al., 2014). Montazeri F et al.
examined the relation among dietary intakes,
obesity, and dental caries in children aged 6-11
years. They concluded that obesity is a risk
factor for developing tooth decay (Montazeri et
al., 2015). In fact, studies considering the
association between dental caries and BMI status
led to inconclusive results. The majority of
studies had a retrospective approach and there is
no evidence on any prospective studies in this
regard to the best of our knowledge.
1.2 Dental caries and diet
The results of investigations showed that the
components as well as cariogenic, cariostatic, and
anticariogenic properties of the diet can have
impact on susceptibility and developing dental
caries (Mobley, 2003, Sanders, 2003).
Anticariogenic agents are foods which can
increase saliva pH to an alkaline level and result
in protection of enamel from caries (Radler and
touger-decker 2007, Touger-Decker and Mobley,
2007). The cariostatic agents are foods that are
not metabolized by microorganisms and cannot
lead to a reduction in salivary pH to values lower
than 5.5 within 30 minutes. The cariogenic agents
are foods or drinks containing fermentable
carbohydrates that are metabolized by
microorganisms; they can cause a drop in salivary
pH to less than 5.5 and lead to demineralization
and plaque formation (Bolan et al., 2007, Touger-
Decker and Mobley, 2007). The important factors
for production of cariogenic property are
including food form, solubility, amount and
frequency of fermentable carbohydrates intake,
nutrients composition, potential to stimulate
saliva, sequence of food consumption, as well as
combinations of foods (Bolan et al., 2007,
Mobley, 2003, Sanders, 2003). In Iran,
Mohammadi et al. investigated the relationship
between dental caries and consumption of sugars
from diet in 5-6 years old children. They found no
significant association between dietary intake and
tooth decay. But, there was a significant
association between using bottle with sweet
drinks through infancy and higher risk of caries
(Mohammadi et al., 2008). In addition,
researchers in another study observed no
significant relationship between consumption of
sugars and fizzy (carbonated) drinks in Tehranian
children (Pourhashemi and Golestan, 2009).
Moreover, a survey was conducted by
Pourhashemi et al. on the assessment of dietary
intakes and their relationship with anthropometric
indices and dental health in 788 primary school
children (7 years old). Dietary intakes were
assessed by 24-h-recalls and food frequency
questionnaire (FFQ). Dietary intakes were
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calculated and compared with recommended
dietary allowance (RDA). Findings of the study
suggested a protective affect for saturated fatty
acids in prevention of teeth decay so that, the
DMFT/dmft was higher in children with an intake
less than 75% of recommendation. Further, they
found that the intakes of calcium, iron, and zinc
from diet are not enough in the children which
can cause malnutrition and failure to thrive. In
addition, a significant relationship was observed
between low intake of calcium and iron and
DMFT/dmft indices; the indices were higher in
children with intakes lower than 75% of the RDA
than those with sufficient intake (Pourhashemi et
al., 2008, Pourhashemi et al., 2007).
The researchers evaluated the association
between consumption of snacks and sweet drinks
on the one hand and tooth decay on the other hand
among a group of male school children (8-12
years old) in Tabriz. The food intakes were
assessed by a validated questionnaire. Snacks
were classified into two groups. The first group
was biscuit, cookie, pastry, sugar, bread, and jam.
The second group included raisins, dried berries,
chocolate, candy, chips, salty snacks, and dried
fruit purees. Drinks group were sweet drinks and
carbonated drinks. The findings showed a high
consumption of snacks and sweet drinks among
children. A higher intake of the mentioned foods
was associated with higher risk of caries (Savadi
Oskoee et al., 2008).
In a survey on population of postpartum
women, the relationship between intake of
calcium, iron, and multivitamin supplements
during pregnancy and dental health was
examined. The consumption of calcium
supplement was associated with a decreased
DMFT. While, the intake of iron supplement was
related to increase of DMFT (Faezi et al., 2014).
Another study also investigated the association
between dietary patterns and dental health
between a group of children with type 1 diabetes
(31 patients) and the healthy group (31 healthy
children). The dietary intakes were evaluated by
FFQ. This questionnaire contained 11 cariogenic
foods (biscuits, chocolate, ice cream, soft drink,
sweetened hot tea, dry fruits, sweetened hot milk,
candies, confectionery cookies and cakes, canned
fruits/ jams, sugary gum) and four foods with
protective properties against decay (walnut and
almond, cheese and bread, apple and cucumber,
sugar-free gums). The consumption frequency of
food items were asked per day or week.
Consumption of cariogenic foods was higher in
the control group than the patients. There was no
difference in using protective foods between
groups except for intake of cheese and bread as
snack which was higher in patients than controls.
However, the mean DMFT did not differ between
the two groups (Bassir et al., 2014).
Ghasempour et al. examined the dental caries
and related factors in preterm and low birth
weight children in comparison with normal birth
weight group. They found no difference between
groups in terms of breast feeding, a combination
of breast and bottle feeding, or snack
consumption (Ghasempour et al., 2009).
Whereas, the results of another study showed a
relationship between early childhood caries and
bottle feeding at night among children aged 1-3
years in Tehran (Mohebbi et al., 2008). Mosahab
P et al. conducted a survey on the association
between food intake and dental caries in a
population of children aged 6-11 years in
Shemiranat, Tehran. Food intake was assessed by
using a FFQ. This questionnaire consisted of 64
food items. The food items were categorized into
21 groups as follows: grain, meat and substitutes,
processed meat (sausages), milk and dairy, sweet
milk and dairy (ice cream, Milk chocolate, milk,
coffee, milk, bananas), vegetables, starchy
vegetables (corn and potatoes), fruits, dried
fruits, nuts, sweets (biscuit, cake, cream cakes,
cookies, pastries, donuts, pastry cream, pancake),
sugar, honey and jam, desserts, bakery
products, salty snacks, sugary drinks, artificial
sweeteners, fruit juice, compote, and tea.
The findings demonstrated a relationship
between higher frequencies of consuming snacks
particularly dried fruits, sweets, sugar, bakery
products, salty snacks and caries. In contrast,
consumption of milk and dairy was inversely
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associated with caries (Mosahab et al., 2011). In
another study, researchers examined children’s
diet related to oral and dental health indices in
Mashhad. Dietary assessment was conducted by
three-day food history. There was no significant
relationship between dmft and main food groups
of food pyramid. But, an inverse association
between intake of fat and protein and dmft was
observed. (Talebi et al., 2007). Ebrahimi M et al.
investigated the dental health and its association
with macronutrients intake and anthropometric
indices among elderly in an elderly dwelling in
Tabriz. Dietary intake and the foods' weights
were assessed by direct observation for three
days. Anthropometric indices were also
measured. The researchers found no significant
relationship between dental status, anthropometric
indices, and dietary intake (Ebrahimi Mamaghani
et al., 2008). Furthermore, in another study, the
association of diet with oral and gum health was
evaluated in a population of preschool children in
Mashhad; no association was reported (Talebi et
al., 2006).
Faezi et al. examined the relationship of dmft
with diet and social factors among a group of
school children (aged 6-12 years) in Tehran. They
found an association between consumption of
cariogenic foods and tooth decay (Faezi et al.,
2012). In addition, the results of another study
showed that prevalence of caries was higher in
children with frequent bottle feeding at night than
the group with breast feeding among a sample of
children aged 4-6 years in Zahedan (Shirzaiy and
Heidari, 2010). Similarly, it was indicated in the
study carried out by Javadinejad et al. that the
caries rate was higher in the premature or
underweight children than children with normal
weight. Moreover, the consumption frequency of
sweets, sugar, and bottle feeding was higher in
the former than latter (Javadinejad et al., 2009).
Eskandarian and Joshan conducted a study about
the relationship between caries and consumption
of iron supplement; they found no association
between tooth decay and intake of iron
supplement (Eskandarian and Joshan, 2006)
1.3 Dental caries and drinking water fluoride
Fluoride is an essential micronutrient for
fortification and stability of apatite matrix in
skeletal tissues and teeth (Hurtado et al., 2000).
One of the major sources of receiving fluoride is
water (Carton, 2006, Osmunson, 2007, Spittle,
2008). All natural waters have fluoride in a wide
range from trace levels to several dozen mg/L
(Hurtado et al., 2000, Whelton et al., 2004). In
the regions where the concentration of fluoride in
the water is naturally low (<0.5 mg/L), it is
recommended to add fluoride to drinking water
(Hurtado et al., 2000, WHO, 2011). However, the
previous studies showed that the high
concentration of fluoride may cause some
problems including dental caries, skeletal
fluorosis, renal and neuronal disorders, as well as
myopathy (Hussain et al., 2003, Hussain et al.,
2010, Pérez and Sanz, 1999, WHO, 2011). So, the
high or low concentrations of fluoride both have
adverse effects on health (Hussain et al., 2003,
Hussain et al., 2010). Due to this reason,
monitoring of fluoride concentration in the
drinking water is crucial (Dehghani et al., 2013).
Many studies were conducted on concentration
of fluoride in drinking water and its relationship
with dental caries. In a survey on a population of
children in Dashtestan, no significant relationship
was observed among level of fluoride in the
drinking water, the number of decayed permanent
teeth (Dt), and the number of decayed deciduous
(dt). But, a weak increase in the Dt and dt scores
with increment fluoride level was reported in the
area with highest water fluoride levels in
comparison with the area having the lowest levels
(Dobaradaran et al., 2008). The findings of
another study in Arsanjan revealed a non-
significant association of water fluoride level with
the Dt and dt scores (Rahmani et al., 2010a).
Dehghani et al. examined the DMFT index and its
relationship with water fluoride among a group of
students aged 7-11 years in 4 districts of Shiraz.
The results indicated that the DMFT index
was higher in districts with low concentrations
of fluoride than districts with desirable
concentrations (Dehghani et al., 2013). Similarly,
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in another survey in Behshahr, it was observed
that the concentration of fluoride in drinking
water was lower than the standard level and the
DMFT index was higher in girls than boys
(Mahvi et al., 2006). Nazemi and Raei evaluated
the concentration of fluoride in the drinking water
and the DMFT index in a population of 7 year-old
children in Shahroud for a period of 6 years
(2004-2009). They found a significant difference
between concentration of fluoride and the DMFT
index in different years. It was also observed that
the DMFT index was increased along with
fluoride levels in the drinking water (Nazemi and
Raei, 2012). This is while, results of another
study showed that fluoride levels were lower in
drinking water of Noorabademamasani than the
national levels. However, a very weak reduction
was observed in the reduction of Dt and dt scores
with increase of fluoride levels in some villages;
this association was not statistically significant
(Rahmani et al., 2010b). Besides, in a survey on a
sample of children aged 6-11 years in Khartooran,
an inverse association was observed between
fluoride concentration in the drinking water and
caries rate (Nazemi and Dehghani, 2014).
Similarly, the study of Davil et al.
demonstrated that the concentration of fluoride in
drinking water was lower than national level in
Mianeh, but, it was within the WHO
recommended range. Additionally, the DMFT
index was higher in children aged 6-9 years in
comparison with national mean. The researchers
suggested that the lower level of fluoride may be
associated with higher DMFT index (Davil et al.,
2013). Whereas, the results of another study
showed no relationship between concentration of
fluoride in the drinking water sources and DMFT
index in a population of guidance school students
in Piranshahr and Poldasht, west Azarbayjan, Iran
(Aghdasi et al., 2014). However, Khademi H and
Taleb M observed lower DMFT index among a
sample of school children aged 7-12 years in
areas with higher fluoride levels in the drinking
water than the areas with lower fluoride levels
(Khademi and Taleb, 2000).
2. PD
PD is a common oral health problem which is
caused by gram negative anaerobic bacteria and
leads to destruction of periodontal tissues,
inflammation and in sever forms, tooth loss
(Borrell et al., 2005, Buhlin et al., 2009, Dalla
Vecchia et al., 2005). The factors which may
increase the risk of PD include smoking, diabetes,
osteoporosis, cardiovascular disease, immune
status of the host, stress, and age (Dervis, 2005,
Genco, 1996, Genco et al., 2005, Ritchie et al.,
2002, Schillinger et al., 2006, Yoshihara et al.,
2004). In addition, behavioral factors such as poor
oral hygiene, tobacco use, and diet are the risk
factors of PD (Al-Zahrani et al., 2005, Pihlstrom
et al., 2005). The results achieved from studies
showed that the adequate intake of various
nutrients including protein, vitamins C, E and D,
beta-carotene, folate, magnesium, and calcium
could have a protective role against PD
(Moynihan, 2005, Touger-Decker and Mobley,
2007). In addition, the researchers reported an
association between higher risk of PD and obesity
(Dalla Vecchia et al., 2005), increased BMI
(Haffajee and Socransky, 2009), and increased
waist circumference (WC) (Reeves et al., 2006).
Few studies were carried out about the association
between nutrition and PD in Iran which focused
on the relationship between BMI, body
composition or a few of nutritional factors such as
omega-3 fatty acids, resveratrol, and PD.
2.1 PD and obesity
Some researchers indicated that there is a
relationship between increased BMI (Dalla
Vecchia et al., 2005, Haffajee and Socransky,
2009, Kopelman, 2000, Nishida et al., 2005, Saito
et al., 2001), WC (Reeves et al., 2006), and
increased risk of PD. In a survey, researchers
investigated the relationship between body
composition and PD in a sample of men aged 30-
60 years. Periodontal status was evaluated by
gingival and plaque indices as well as means of
attachment loss. According to gingival and plaque
indices, bleeding from the gingival margin and
visible plaque receives a score of ―1,‖ whereas,
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lack of bleeding and visible plaque get a score of
―0 ‖ Attachment loss (the distance from the
Cementoenamel junction to the base of pocket)
was measured by Williams periodontal probe
(PWD, Hu-Friedy Immunity, USA) for all of the
teeth on four areas (buccal, mesial, distal, and
palatal or lingual) and the mean of values were
obtained. Based on the assessment, the
individuals were categorized into 4 groups: Group
1: normal with no gingival inflammation and no
attachment loss, Group 2: simple gingivitis with
gingival inflammation and no attachment loss,
Group 3: initial periodontitis with gingival
inflammation and attachment loss of <2 mm, and
Group 4: established periodontitis with gingival
inflammation and attachment loss of more than 2
mm. The anthropometric measurements included
weight, height, WC, and BMI. The body
composition (body water, body fat, skeletal
muscle, and bone mass) were analyzed by
bioelectrical impedance analysis (BIA) and
diagnostic scale. The results indicated a
relationship between severe forms of PD and
body composition in males. In this regard, the
mean BMI, WC, and the percentage of body fat
were significantly higher in the participants with
periodontitis in comparison to healthy and
gingivitis groups. Meanwhile, the percentage of
body water was lower in the periodontitis group
than other groups. In addition, the findings of
comparisons between groups showed that the
percentage of skeletal muscle was greater in the
healthy individuals and patients with gingivitis in
comparison with the group with periodontitis.
But, the bon mass was higher in the healthy group
than participants with PD (Salekzamani et al.,
2011).
Sarlati et al. conducted a case control study to
examine the association between obesity and
periodontal status among a group of Iranian
adults. The assessment of periodontal status
(including Plaque Index (PLI), Probing Pocket
Depth (PPD) and Clinical Attachment Level
(CAL)), BMI, and WC were carried out.
Moreover, socio-demographic status and risk
factors of PD (age, sex, education, time elapsed
since last dental visit, smoking, and diabetes)
were examined. The findings showed that there
was a relationship between overall and abdominal
obesity and periodontal problems rate. Thus, PPD
and CAL were significantly higher in the obese
participants than controls (Sarlati et al., 2008).
In a case-control study, the relationship
between BMI, serum lipids, and PD were
investigated among a population aged 30-50 years
(55 healthy subjects and 55 patients with chronic
periodontitis with same age range). The exclusion
criteria were systemic disease, medication, being
pregnant, smoking, alcohol, and addiction. The
Clinical attachment loss (CAL) was examined by
measuring the interval from the cementenamel
junction to the bottom of the gingival crevice as
the index of PD. The PD was defined as presence
of proximal or mesial to distal CAL greater than 4
mm in two or more teeth based on the previous
studies (Page and Eke, 2007). The researchers
defined the 3-4 mm attachment loss as moderate
PD and attachment loss of more than 5 mm was
considered as severe PD. The lipid profile was
measured via enzymatic method and auto
analyzer. The cutoff points of lipid profile based
on laboratory’s recommendation were as follows:
triglyceride (TG) higher than 200 mg/dL, total
cholesterol (TC) more than 200 mg/dL, low
density lipoprotein cholesterol (LDL-c) higher
than 130 mg/dL, and high density lipoprotein
cholesterol (HDL-c) less than 35 mg/dL.
Anthropometric variables included weight, height,
and BMI. The results indicated that BMI was
significantly higher in PD group than healthy
participants. However, in the patients with PD,
TG was higher, while LDL-c, HDL-c, and TC
were lower in comparison to controls; these
differences were not statistically significant
(Fatemeh et al., 2015).
2.2 PD and dietary factors
Findings of the previous investigations
indicated that a balanced diet and adequate intake
of nutrients, such as protein, vitamins C, E and D,
beta-carotene, folate, magnesium, and calcium,
might prevent from PD. On the other hand,
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malnutrition and imbalanced diet might lead to
increased risk of PD (Al-Zahrani et al., 2005,
Moynihan, 2005, Pihlstrom et al., 2005, Touger-
Decker and Mobley, 2007). In addition, some
surveys reported the beneficial effects of omega-3
fatty acids (Farhad et al., 2014, Jenabian et al.,
2013) or natural polyphenols derived from plants
such as resveratrol as adjunctive therapy in the
treatment of PD (Rizzo et al., 2012). Omega-3
fatty acids are polyunsaturated fatty acids
(PUFAs) which are found in the marine sources,
such as eicospentaenoic acid (EPA) and docosa-
hexaenoic acid (DHA), and vegetable sources,
such as alpha-linolenic acid (ALA) (Campan et
al., 1997, Eberhard et al., 2002, Zhao et al.,
2007). The studies suggested that omega-3 fatty
acids have anti-inflammatory, protective, and
therapeutic effects in different inflammatory
diseases such as diabetes mellitus (Caballero,
2004, Calder, 2006), cardiovascular diseases
(Calder, 2006, 2014, Ross, 1999), and PD (Chee
et al., 2016). Resveratrol is a polyphenolic
compound which is taken from food sources
including grapes, peanuts, pistachio, and
cranberry (Szkudelska and Szkudelski, 2010,
Vallianou et al., 2013). The researches
demonstrated that resveratrol has anti-microbial
(Fordham et al., 2014), anti-inflammatory, anti-
apoptotic (Brasnyó et al., 2011), anti-cancer
(Uysal et al., 2011), antioxidant properties and
can be effective in management of PD (Bhatt et
al., 2012, Brasnyó et al., 2011, Park et al., 2009).
Few studies were conducted on the relationship
between nutrition and PD in Iran and those
published focused on the effect of a few of
nutritional factors such as omega-3 fatty acids
or resveratrol. Jenabian N et al. conducted a
clinical trial to investigate the influence of
omega-3 fatty acids in treatment of moderate
gingival inflammation in a population of patients
aged 20-40 years. The patients were divided into
two groups. The intervention group was given
1000 mg of omega-3 PUFAs and the control
group received 1000 mg of glucose as a placebo
daily for 10 days as gelatinous capsules. Gingival
index (GI), bleeding index (BI), and plaque index
(PI) were evaluated at baseline and after 5, 10,
and 20 days. The results showed a significant
greater reduction of indices in the omega-3
supplemented group compared with controls. The
study proposed that supplementation with omega-
3 PUFAs might be effective in the treatment of
gingivitis (Jenabian et al., 2013). In a another
study, the researchers evaluated the effect of low-
dose aspirin plus Omega-3 fatty acids on
management of chronic periodontitis in
comparison with low-dose doxycycline among 45
patients with mild to moderate chronic
periodontitis. The phase 1 of periodontal
treatment was carried out for patients and then,
the participants were assigned into three groups.
Group one received Omega-3 (300 mg/d) plus
aspirin (80 mg/d). Group 2 received doxycycline
(20 mg/d) and group 3 was given a placebo tablet
daily. The clinical parameters including bleeding
on probing (BOP), periodontal pocket depth
(PPD), and clinical attachment loss (CAL) were
measured at the baseline and after six weeks. The
findings showed that the mean values of BOP,
PPD, and CAL were lower in the test groups than
placebo group. Furthermore, the reduction of
indices was higher in the omega-3 group when
compared to doxycycline group (Farhad et al.,
2014).
Zare Javid et al. conducted a double-blind
clinical trial to evaluate the influence of
resveratrol supplementation on blood glucose,
TG, periodontal status, and some inflammatory
markers in type 2 diabetic patients with PD. The
patients were divided to two groups. The
intervention group was given 480 mg/d
resveratrol capsules (480 mg Polygonum
Cuspidatum providing 240 mg resveratrol) while
the control group received placebo capsules
(contained 480 mg starch) (2 pills) for four
weeks. The non-surgical treatment, including
removal of dental plaque, scaling, and root
planning was conducted for all patients.
Anthropometric indices, i.e., 24-hour dietary
recall, fasting blood glucose, serum level of
insulin, TG, interleukin 6 (IL6), tumor necrosis
factor alpha (TNFα), insulin resistance (HOMA-
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IR), and pocket depth were examined in all
individuals before and after intervention. There
were no significant differences in the mean levels
of fasting blood glucose, serum level of TG, IL6,
and TNFα between the two groups after
intervention. However, the mean serum levels of
fasting insulin and HOMA-IR were significantly
lower in the intervention group than the controls
after intervention (P = 0.02, P = 0.045, and P <
0.001, respectively). Moreover, the results
showed that the mean serum level of IL6 was
decreased significantly in the intervention group
(Zare Javid et al., 2016).
3. Oral cancer and nutrition
Oral cancer is one of the most common
cancers worldwide (Baharvand et al., 2014,
Krishnaswamy et al., 1995). The main risk factors
of oral cancer are alcohol and tobacco use, some
viral infections, genetics, and diet (Itagappa and
Rao, 2004, Paul et al., 2002). Nutrients such as
vitamins A, E, C, beta carotene, zinc, and folate
can have a protective effect against oral
carcinogenesis by means of the following
mechanisms: prevention of procarcinogens
activation, inhibition of chromosomal aberration,
and inhibition of the development in lesions with
malignancy properties (Giovannelli et al., 2002,
Scardina and Messina, 2012, Taghavi and Yazdi,
2007). Moreover, a diet characterized by lower
intake of energy, saturated fat, red or processed
meats, as well as higher intake of fruits,
vegetables, and cereals are associated with
decreased risk of oral cancer (Taghavi and Yazdi,
2007). In addition, some studies showed that
changes in the serum levels of copper, ferritin,
and zinc may be involved in the pathogenesis of
cancers including oral cancer because they have a
considerable role in the structure and function of
many enzymes including antioxidant enzymes
(Beguin et al., 1987, Fukuda et al., 2004, Prasad,
1994, Prasad et al., 1992, Toyokuni, 1999,
Yelinova et al., 1996). There were a few studies
investigating the relationship between nutrition or
diet and oral cancer in Iran. Baharvand M et al.
evaluated the serum levels of ferritin, copper, and
zinc among 60 patients with oral and
maxillofacial cancer and 66 healthy individuals as
controls. The results indicated that the mean
serum levels of ferritin, copper, and zinc were
significantly higher in the patients than the
healthy group (P < 0.001) (Baharvand et al.,
2014).
Discussion
The current review showed that studies
investigated the association between BMI and
dental caries led to inconsistent results. So, it
seems that other factors such as socio-economic
factors or oral hygiene might be involved in the
development of dental caries (Bafti et al., 2015,
Bahrololoomi et al., 2014, Edalat et al., 2014,
Faezi et al., 2013, Ghasempour et al., 2011,
Khosravani et al., 2014, Malek Mohammadi et
al., 2012, Mojarad and Maybodi, 2011, Montazeri
et al., 2015, Sadeghi and Alizadeh, 2007, Sadeghi
et al., 2011, Shahraki et al., 2013). In addition,
researchers found an association between higher
consumption of cariogenic foods and higher risk
of dental caries (Faezi et al., 2012, Javadinejad et
al., 2009, Mossaheb et al., 2011, Savadi Oskoee
et al., 2008). Although the low intake of dietary
iron and calcium was related to higher rate of
caries (Pourhashemi et al., 2008, Pourhashemi et
al., 2007), a relationship was observed between
the high consumption of iron supplement and
caries among postpartum women (Faezi et al.,
2014). In this regard, adequate intake of dietary
protein, fat (Talebi et al., 2007), and saturated
fatty acids (Pourhashemi et al., 2008,
Pourhashemi et al., 2007) were associated with
decreased tooth decay. In addition, bottle feeding
at night increased the risk of caries in children
(Javadinejad et al., 2009, Mohammadi et al.,
2008, Mohebbi et al., 2008, Shirzaiy and Heidari,
2010). It was observed in majority of studies that
the rate of dental caries was higher in the areas
with lower levels of fluoride drinking water than
the areas with higher fluoride levels, in Iran
(Davil et al., 2013, Dehghani et al., 2013,
Khademi and Taleb, 2000, Mahvi et al., 2006,
Nazemi and Dehghani, 2014, Rahmani et al.,
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2010a). In addition, researchers found an
association between higher values of BMI, WC,
and body fat percentage with higher severity of
periodontitis (Fatemeh et al., 2015, Salekzamani
et al., 2011, Sarlati et al., 2008). Furthermore,
the literature suggested that using omega 3 fatty
acids (Farhad et al., 2014, Jenabian et al., 2013)
or resveratrol (Zare Javid et al., 2016)
supplement can be useful in the management of
periodontitis. Investigations in Iran have also
revealed that serum levels of ferritin, copper, and
zinc were greater in the patients with oral cancer
compared with healthy participants (Baharvand
et al., 2014).
Finally, the results of this review indicated that
appropriate nutrition and diet could be effective in
maintaining oral health and prevention of oral
disease. Nonetheless, the majority of surveys
were concentrated on assessment of the
association between nutrition or diet and dental
caries. A few studies were carried out to
investigate the relation between nutrition or diet
and other oral disorders such as PD or oral
cancer. Moreover, a few nutritional or dietary
factors were evaluated in these studies.
Consequently, more studies are recommended to
examine the association between nutrition and
oral health that include several dietary or
nutritional factors and various types of oral
disease. Furthermore to the best of our knowledge
there has been no prospective cohort studies on
the association between dietary factors and oral
diseases. Conducting this type of studies might
help to see if previous associations found by
retrospective studies are causal or not.
Conclusions
Nutrition and diet are related to oral health and
prevention of oral disease. Further studies are
therefore recommended to evaluate the
association between nutrition and oral health with
considering various dietary or nutritional factors
and different types of oral problems in Iran.
Acknowledgements
The authors thank the Department of Nutrition
in Shahid Sadoughi University of Medical
Sciences for supporting of the study.
Authors’ contributions
Sangsefidi ZS collected data. Sangsefidi ZS
and Salehi-Abargouei A wrote the draft of article.
Salehi-Abargouei A approved the final version of
manuscript to be submitted. All authors read and
approved the final version of article.
Conflicts of interest
The authors disclose no conflict of interest
associated to the article.
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